A Lesson from My Daughter in Quality Improvement by Tamala Bradham, Ph.D.

Insanity is doing the same thing over and over again but expecting different results (Albert Einstein, n.d.).  In healthcare, evidence strongly suggests that services rendered are not meeting the patients’ needs, are not based on the best scientific knowledge available, and are not provided in an efficient manner that minimizes costs, resources, and time (Berwick & Hackbarth, 2012).  As much as 21 to 47% of healthcare costs may be unnecessary, or even counterproductive, to improved health (Berwick & Hackbarth, 2012).  Many patients, doctors, nurses, and healthcare leaders are concerned that the care delivered is not, essentially, the care that should be received (Institute of Medicine [IOM], 2001).  So why do we keep doing the same thing over and over again?  Why are we so resistant to process improvement?

The answer is change.  When I ask about making a change, I often hear “I don’t have the time”, “There is no money for that”, or “That is not a problem, we are fine just with the way we are doing it”.  Change is hard.  Did you know that there are multiple stages a person can go through when making a change and demonstrating competency?  Here they are:

Unconscious incompetence: The person does not understand or know how to do something.  Furthermore the person does not recognize the shortfall. They may deny the usefulness of the skill.  To move forward, the person has to step outside his or her comfort zone.

Conscious incompetence:  The person does not understand or know how to do something, but he or she does recognize the deficit, as well as the value of adding the new skill in addressing the deficit.

Conscious competence: The person understands or knows how to do something but still needs support and time to demonstrate this new skill or knowledge.

Unconscious competence: The skill or knowledge is “second nature” and can be performed easily. The person can now teach it to others.

Complacency: Beware – This can happen to anyone.  The person becomes too comfortable and only does the same thing over and over again.  In this stage, the person misses opportunities for growth and change.  Not everyone enters this stage but it is worth mentioning.

At any point in time, we could be in all levels because hopefully we all still have things to learn, new skills that we are acquiring, and sharing our knowledge with junior staff.

But what I wanted to know was how do you move from one step to another?  While I can’t take credit for this idea, my daughter was on to something when she shared “BanBossy” with me by the Girls Scouts and LeanIn.Org.  The last step mentioned in “BanBossy” is the thought we feel better about ourselves when we show that we have accomplished something by stepping outside our comfort zones, overcome barriers, and master challenging tasks.  Many people struggle with stepping outside their comfort zones as they worry about making a mistake, what people will think of them, failing, or disappointing others.  We need to be willing to try new things and not worry about perfection.

So what does this have to do about quality improvement – everything!  Really take a look at your practice.  Is there anything that is a barrier to patient access, unnecessary steps in a process, or other supplies you could use that would be less expensive but do the task?  In quality improvement, we should strive to be in the:

Conscious Incompetence exploring new ways to improve;

Conscious Competence perfecting our system and knowledge; and

Reaching outside our Comfort Zone in trying new ways to improve healthcare!


BanBossy.Org. (2014).  Retrieved from http://banbossy.com/.

Berwick, D. M., & Hackbarth, A. D. (2012).  Eliminating waste in US health care.  Journal of the American Medical Association, 307(14), 1513-1516. doi: 10.1001/jama.2012.362

Businessballs.com.  (2014).  Conscious competence learning model. Retrieved from http://www.businessballs.com/consciouscompetencelearningmodel.htm

Institute of Medicine [IOM]. (2001).  Crossing the Quality Chasm: A new health system for the 21st century.  Retrieved from http://iom.edu/Reports/2001/Crossing-the-Quality-Chasm-A-New-Health-System-for-the-21st-Century.aspx